Prior Authorization Specialist/Licensed Practical Nurse

Spectra Health - Grand Forks, ND

Hybrid - Grand Forks, ND

Ambulatory Health Care Services

About the position

The Prior Authorization Specialist is responsible for all aspects of the prior authorization process, which includes reviewing and interpreting medical record documentation for patient history, diagnosis, and previous treatment plans. Utilizes payer-specific approved criteria to determine medical necessity or the clinical appropriateness for the company's products. Submits pertinent demographic and supporting clinical documentation with authorization requests timely to avoid unnecessary delays in patient treatment. The Prior Authorization Specialist reports directly to the Medical Clinic Manager.

Responsibilities

• Collecting all the necessary documentation, contacting the client for additional information and completion of the required prior authorization in order to proceed with testing and treatment.
• Complete, timely, and accurate identification and submission of prior and retro authorization requests to the payors.
• Interacts with clients, insurance companies, patients, and sales representatives, as necessary, to request prior authorizations.
• Responsible for documenting and tracking account activity, updating patient and claim information.
• Demonstrates proficiencies with the diverse billing systems to ensure all functionalities are utilized for the most efficient processing of claims.
• Identifies prior authorization trends and/or issues resulting in delayed claims processing from initial submission through final insurance determination.
• Provides the highest level of customer service to internal and external clients.
• Schedule lab work, tests, procedures, referrals, or surgeries according to standards.
• Completes and codes laboratory and radiology requests, obtaining waivers from patients as necessary.
• Complete training and perform CLIA waived lab tests as allowed by certification/license.
• Provides triage for urgent patient calls and discussion with provider.
• Identifies significant changes or high-risk situations in patient's condition and takes appropriate actions.
• Prepares patients for exams and assists with procedures as provider requests.
• Maintains an efficient flow of patients.
• Answers telephone, routes calls, and takes accurate and complete phone messages for the provider.
• Provides patient/patient's family with appropriate education based on identified needs.
• Completes all charting and documentation within the EHR of all authorized medication refills and instructions given.
• Notifies Medical Clinic Manager of any complaints, unsatisfactory outcomes, or special requests.
• Notify patients of lab reports when requested by provider.
• Prepare instruments for CSR.
• Check medications and supplies for outdates and communicate supply needs to appropriate staff.
• Other duties as assigned such as phlebotomy, scanning, performing EKGs.

Requirements

• Holds current valid North Dakota license as an LPN.
• Minimum of 2 years of customer service experience in the healthcare industry preferred.
• Minimum of 2 years of Epic software experience.
• Proficiency in Medical Billing: ICD and CPT coding highly desired.
• Knowledge in Medicare and third-party payer regulations and guidelines highly desired.
• CPR/BLS certification is required or must be obtained within six (6) weeks of employment.

Nice-to-haves

• One to two years clinical nursing experience, preferably in a clinic setting.